Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 11275378-1205 | UT |
N | 208600000X | Surgeon | 11275378-1205 | UT |
Y | 2086S0102X | Surgical Critical Care | 11275378-1205 | UT |
NPI | 1154611986 |
---|---|
Provider Name | Anthony Wayne Bacon |
First Address | Salt Lake City, UT 84132-0002 |
Second Address | Salt Lake City, UT 84132-0002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2011 |
Last Update Date | 10/06/2019 |